WHAT'S UP DOC? New daily persistent headache

Tuesday

Feb 21, 2017 at 4:35 PMFeb 22, 2017 at 1:15 PM

By Dr. Jeff Hersh/Daily News Correspondent

Q: About four months ago my best friend developed a headache that just didn’t seem to want to go away. Her doctor did some tests and said she had a new daily persistent headache. Isn’t this more a description of her symptoms than a diagnosis?

A: Unfortunately, chronic headaches (ones that occur for at least 15 days per month for at least three months) are a common condition, affecting up to 4 percent of the adult population. There are multiple different types of chronic headache; New Daily Persistent Headache (NDPH) is a very descriptive name for one type. Although the actual incidence of NDPH is unknown, it is thought to be rare, affecting about one to 10 per 10,000 people.

The diagnosis of NDPH is made based on the presence of a persistent headache that has a distinct, abrupt (but usually not sudden like a thunderclap) and usually clearly remembered date of onset that then becomes continuous and unremitting within 24 hours. For the diagnosis to be made the symptoms must persist for at least three months, and no other type of headache diagnosis (such as central venous sinus thrombosis, headache from spontaneous cerebrospinal fluid leak, pseudotumor cerebri, giant cell arteritis, brain tumor, as well as many other possible causes) better explains the symptoms. More than 80 percent of patients with NDPH can specify the exact date that their symptoms began, and this is one of the distinguishing features of this condition.

The underlying cause of NDPH is not well understood. In some studies, it has been noted that over half of NDPH patients had their symptoms begin at the time of a flu-like or other viral illness (such as Epstein Barr virus, the cause of mononucleosis, Herpes Simplex Virus, or other viral illnesses), hence an inflammatory and/or autoimmune etiology may be possible. However, other stressors (such as trauma, head injury, surgery, other) have been associated with onset of NDPH as well.

NDPH can occur in anyone, although it is diagnosed in women more commonly than men. Children are diagnosed more frequently than adults (most commonly in the teen years). The typical age of onset in adults is between ages 20 and 30, but it has been diagnosed in people of all ages. Over half of people diagnosed with NDPH have no history of a prior headache condition.

The specific features of the headaches in NDPH patients vary from patient to patient. The initial diagnostic criteria for this condition did not allow “migraine” headache features (like sensitivity to light or sound, increased pain perception to typically non-painful stimuli, nausea, etc.), but it is now realized that over half of all NDPH patients have “migraine-like” symptoms. The headache is bilateral in about three quarters of patients, and is usually of a throbbing or pressure-like nature, lasting hours to all day (in fact about three quarters of patients have some level of headache pain all day), and being of a moderate to severe intensity. As you can imagine from this description, many patients are quite disabled by this disease.

There is no diagnostic test for NDPH. The initial testing, typically an MRI of the brain with intravenous contrast, is done to rule out other causes for the chronic headache. Other studies, including other specialized types of MRI, a lumbar puncture (sometimes called a spinal tap), and possibly other tests, may be indicated as well.

There are no specific treatments for NDPH. Treatments typically used for other headaches disorders, including certain antidepressant medications, some anti-seizure medications, NSAIDs, botulinum toxin injections, others. The selection of medication is often based on the type of headache symptoms the patient has. For those with migraine-like features, medications usually used for migraines are often selected as the initial treatment choice, and for those with tension headache-like symptoms the initial medication selection would be medications that are typically effective for that condition.

There are thought to be two subtypes of NDPH. One subtype seems to be self-limiting and resolves on its own, typically within two years. The other subtype is often refractory to even aggressive treatments, and is persistent for many years and even decades. NDPH can be disabling, compromising the quality of daily life for the patient and often making it impossible to hold down a job.

People with NDPH should be followed by someone who specializes in headache diagnosis and treatment. Because the symptoms of NDPH overlap with other chronic headache conditions, it is crucial to evaluate for those conditions since many of them have effective treatment options.